In the early stages of Mycobacterium tuberculosis (Mtb) infection, irreversible tissue necrosis occurs as the result of localized lung inflammation. The bactericidal mechanism of macrophages and neutrophils, that are supposed to control the infection, in fact cause lung tissue damage and thus create a microenvironment that favors Mtb persistence. While Mtb is primarily an intra- cellular pathogen, we and others have shown that drug-tolerant bacilli can persist extra- cellularly in lesions with necrosis. Our long term goals is to determine whether restoring antioxidant capacity therapeutically will prevent the establishment of persistent, drug-tolerant bacilli thus rendering conventional anti-tuberculosis therapy more effective in animals and humans. Central to our proposal is the use of experimental Mtb infections in guinea pigs which develop primary lesion necrosis similar to humans with naturally occurring tuberculosis. Our hypothesis is that by restoring therapeutically the antioxidant defenses regulated by the host transcription factor nuclear redox factor2 (Nrf2) in Mtb-infected guinea pigs, conventional anti-tuberculosis drug therapy will be more effective against persistent, drug-tolerant bacilli. Our preliminary data shows that oxidative stress exists in human and guinea pig Mtb lesions. These lesions have excessive oxidative stress that depletes systemic and pulmonary antioxidant defenses. Oxidative defenses in the host are regulated, in part, by the transcription factor Nrf2. In human and guinea pig Mtb lesions, Nrf2 is defective since it fails to translocate from the cytoplasm to the nucleus. As a result, other downstream antioxidant proteins are not expressed in lesions. The aim of this grant is to: Resolve whether Nrf2 targeted antioxidant therapy will increase the efficacy of anti-tuberculosis drugs. We will accomplish this aim by (1) further defining the role of oxidative stress and the depletion of Nrf2- regulated antioxidant defenses in the pathogenesis of lesion necrosis and Mtb persistence, (2) determining whether antioxidant drugs can restore Nrf2-regulated endogenous antioxidant defenses and (3), determining whether Nrf2 inducing drugs can be used to enhance the effectiveness of current anti-tuberculosis drugs by eliminating the persistence of drug-tolerant bacilli. By better understanding the pathogenesis of Mtb persistence and drug-tolerance, new treatment strategies can be added to the global fight to control human tuberculosis. PUBLIC HEALTH RELEVANCE: As the body fights the bacterium that causes human tuberculosis, permanent tissue damage occurs, which allows the bacterium to hide and avoid being killed by antimicrobial drugs. Our research is aimed at preventing tissue damage and bacterial persistence so that antibiotics are more effective and the length of time required for patient treatment is reduced.